Neurogenic bladder and bowel treatment

Early in life, management is focused on keeping pressures low, maintaining a safe system. Infants and young children are in diapers regardless. As the child approaches the school year, the focus starts to shift towards social continence , assuming the child is otherwise doing well. Social continence means that we will have to prevent random leakage, make sure that the pressures are safe while storing the urine and arrange for a convenient way to empty the bladder. For the urologist to achieve these goals safely, a thorough understanding of the patient's nerve injured bladder is required. And it takes a strong team effort by everyone, including the urologist, the nurses and therapists and most importantly the patient and family. The condition, and therefore the management, never take a holiday.

We can create safe storage volumes and pressure, if needed, with the use of bladder relaxing medications, such as Ditropan, Vesicare, Detrol, and other similar meds. If the oral medications do not achieve the goals, Botox injections are often considered. Botox is highly effective at preventing the bladder from contracting or squeezing. But it only lasts a few months and in children must be injected under anesthesia. If these approaches fail, the bladder must be augmented, or enlarged. This is a major surgery and also requires a major commitment by the family to be diligent in the care of the child after surgery.

In some cases, the bladder does not leak until it becomes very full. In other cases, there is decreased sphincter tone and the bladder leaks continuously, especially with activity. The patient has an incompetent sphincter. There are no medications that will tighten the sphincter. Surgery is the only way to create dryness in these patients. There are a number of different surgeries to achieve this, each with advantages and disadvantages.

To achieve emptying we start intermittent catheterization. With rare exception, this is at the center of any management that accomplishes safe storage pressures, continence and effective emptying. A catheter must be inserted into the bladder several times a day to empty the bladder. It most commonly is inserted through the urethra, the natural urinary channel, or through a constructed channel that opens on the abdomen and goes into the bladder. This is very useful for older children and teens in wheelchairs, especially females. Once we have a bladder that holds urine and does not leak, the bladder must be emptied on a scheduled basis. Major deviation from the schedule can lead to harm for the patient.

Bowel management

The bowels are equally affected. And they have the same basic problems as the bladder, failure to hold or failure to eliminate. Early in life, management is focused on keeping the stool moving through. Later we are again looking for ways to achieve social continence. Oral agents will soften the stool and stimulate passage but the timing of evacuation is totally unpredictable. The only way to have a timed elimination is to work directly at the level of the colon, or large intestine, where the stool is stored. This is done most commonly with suppositories or enemas through the bottom. While this can be effective, it has a lot of limitations, especially as the patient gets older and wants to be more independent. We perform continent cecostomies. A channel is constructed that goes from the skin directly into the upper part of the large intestine. Now the enema can be flushed from the top of the colon down (antegrade enema) and the flushing can be performed by the patient while sitting comfortably on the toilet. As I tell my patients, if you are going to wash off a slicky slide covered with mud, would you wash from the bottom up or the top down. The results have been very gratifying in over 90% of the cases and often life changing.

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